Lower extremity claudication (also sometimes referred to as intermittent claudication [IC]) is often the presenting symptom of peripheral artery disease (PAD). Claudication is defined by exertional calf or leg pain caused by muscular ischemia, which resolves with rest.

The prevalence of PAD increases significantly with age. Savji et al [1] reviewed screening ultrasound studies from a population study of more than 3.6 million participants and noted the prevalence of any vascular disease to increase from 2% in those in the age range of 40 to 50 years to 32.5% in those aged 91 to 100 years (P = .0001; Fig. 1). Claudication prevalence also increases with age and is especially common in those with cardiovascular risk factors, affecting up to 5% of individuals older than 65 years. Claudication is not limb-threatening in itself, as annual rates of progression to critical limb ischemia are low (1%–2%). Claudication does, however, significantly impairs walking ability and quality of life in older adults [2]. Revascularization for claudication should therefore be performed selectively on good-risk candidates with persistent, lifestyle-limiting symptoms despite optimal medical and exercise therapy. Conversely, revascularization should not be performed to lower future amputation risk.

The updated Society for Vascular Surgery (SVS) guidelines reinforce the importance of shared decision making and comprehensive evaluation of risks, benefits, and patient-centered outcomes when considering revascularization for claudication. This individualized approach becomes particularly crucial in older adults where comorbidities, functional status, and treatment goals may vary significantly among patients, requiring careful consideration of each individual's clinical circumstances and preferences [3].

Managing claudication in the aging population poses unique challenges, as many patients have multiple comorbidities limiting treatment options, and functional preservation is a key goal.

Management of claudication centers on two fundamental objectives: (1) cardiovascular risk reduction to prevent disease progression and adverse events, and (2) symptom improvement to enhance walking capacity and quality of life. All patients with PAD, including those with claudication, require best medical therapy, including smoking cessation, lipid-lowering therapy, antithrombotic therapy, glycemic control, and blood pressure treatment, as indicated [4]. However, these measures alone often do not sufficiently improve walking impairment. Therefore, dedicated claudication therapies are used, traditionally spanning exercise training, pharmacotherapy, and invasive interventions.

Exercise therapy has long been recognized as a first-line treatment for claudication. Supervised exercise therapy (SET), typically treadmill walking under medical supervision, has a class IA recommendation as initial therapy in practice guidelines [[4], [5], [6]]. Despite proven efficacy, access and adherence to supervised programs remain problematic, prompting interest in home-based exercise therapy (HBET) [7].

Revascularization via endovascular angioplasty/stenting or surgical bypass can provide more immediate symptom relief by improving blood flow. Although risk of amputation is low among patients with claudication (particularly among nonsmokers on appropriate risk reduction pharmacotherapy), loss of patency after a revascularization procedure may be associated with sudden progression to limb-threatening ischemia rather than a return to baseline claudication symptoms. Older patients may be at higher procedural risk, and emerging evidence suggests that invasive treatments for claudication do not necessarily confer long-term benefit and may accelerate disease complications, including amputation [8,9]. Careful patient selection and adherence to appropriate use criteria for revascularization are therefore important to avoid unnecessary amputation risk.

This review focuses on lower extremity claudication management in adults older than 65 years, examining each therapeutic modality. Through this comprehensive overview, clinicians will be better equipped to implement evidence-based, individualized care plans for older adults with claudication.